Charging for 'risky behaviour' a flawed plan

If people aren't put off by health risks with smoking, then paying extra for health care won't stop them.

Miles Eliason

Our health resources must be used wisely, but charging people for taking "avoidable health risks" makes no scientific, economic or logistical sense, writes Jennifer Doggett.

Terry Barnes's proposal for people who take avoidable health risks to be penalised when they access public health services is unscientific, impractical, morally questionable and not supported by economic data.

It is unscientific because it is based on a false understanding of the relationship between risk behaviours and diseases. Research into most so-called "lifestyle-related" diseases has demonstrated a statistical correlation at the population level between specific behaviours and certain diseases.

This is different from identifying a direct causal relationship in individuals. Most diseases are the result of a complex, and poorly understood, interaction of a range of factors, including those over which people have no control (such as their genetic make-up and their in-utero and early childhood environment).

Even smoking - one of the best documented and well-researched risk behaviours - has a widely varying impact on the health of individuals. In fact, only about 50 per cent of all smokers will die from a tobacco-related illness and just 10 per cent of all smokers will develop lung cancer. Judging the impact of smoking on any one individual's health is mind bogglingly complex. For example, to compare the relative health risks taken by a heavy smoker who exercises regularly with a sedentary light smoker would require information way beyond that available to current medical science.

Further complicating this issue is the fact that most so-called "risk" behaviours can be beneficial in certain situations and/or for certain people. In fact, smoking has been shown to reduce the risk of Parkinson's disease. Does this mean that people seeking treatment for this condition would be penalised for not smoking? Absurd perhaps, but an example of where we can end up once we descend down this moral slippery slope.

Another logistical hurdle is the often decades-long lag time between risk behaviours and diseases. In disease terms what an individual was doing 30 years ago is generally more relevant than what he or she did yesterday. Ethical problems aside, is it really conceivable that, when presented with a 75-year-old woman with early stage osteoporosis, a hospital would have to determine whether or not she undertook regular weight-bearing exercise 30 years previously before administering treatment?

This may be speculative but what's certain is that this proposal would impact more upon those who are already disadvantaged in our community. Indigenous Australians, people with mental illnesses and those who are homeless and/or unemployed have much higher rates of smoking and other risk behaviours than the affluent and privileged. Imposing additional penalties and barriers on people already experiencing poorer health would increase the already wide health gap in our community.

This undermines the findings of research on the social determinants of health that has demonstrated that, independent of specific behaviours, people classed as "low status" in a society have a higher rate of death and disease than those classed as "high status". Unless one subscribes to a morally repugnant theory that a particular class, race or culture is somehow intrinsically more reckless or irresponsible, the logical conclusion is that conditions of inequity themselves create an environment less supportive of good health.

If dying a slow and painful death from lung cancer or emphysema is not a disincentive to take up or continue smoking then a higher co-payment or delay in receiving treatment for these conditions is unlikely to be effective.

Based on this research, Barnes's argument could in fact be used to support the reverse of his argument, i.e. the imposition of health care penalties on those who are born into conditions of relative power and affluence, due to their unfair head start in life.

In fact, international evidence shows us that if we want to increase our overall health and wellbeing we should be promoting greater - rather than less - equality within our community and minimising division. Where significant inequality exists, even the wealthiest societies, such as the US, achieve less than average health outcomes, despite spending more on health care than any other country.

Another important counter-argument to Barnes's proposal is that it is very unlikely to work as a deterrent to undertaking risk behaviours. Research has shown that while financial incentives can encourage simple, short-term lifestyle changes, they do little or nothing to reduce risk behaviours over the long term. Intuitively, this makes sense. If dying a slow and painful death from lung cancer or emphysema is not a disincentive to take up or continue smoking then a higher co-payment or delay in receiving treatment for these conditions is unlikely to be effective.

Finally, Barnes's proposal makes no economic sense as it is based on a false assumption that healthy people cost the system less than sick people. This may be true at any given point in time, but over the course of a lifetime, data suggests that healthy people actually end up costing our health system more. This is due to the fact that even the purest of living among us do eventually die and people with healthy lifestyles typically die at an older age and more slowly than those with unhealthy lifestyles. The man who drops dead of a heart attack at 69 will probably use much lower levels of health resources than the one who dies at 95 after years of treatment for slow-growing prostate cancer, low-grade heart disease, Type 2 diabetes and dementia.

Barnes is correct to emphasise the importance of ensuring our health resources are being used to deliver the best value to the community. However, his proposal is logistically flawed, not supported by scientific or economic data and fails to count the cost of increasing discrimination and inequality on both our health system and our community as a whole.

Jennifer Doggett is a Fellow of the Centre for Policy Development and a consultant working in the health sector for a number of professional, industry and consumer groups. View her full profile here.